codedog
True Blue
not sure would this be 44120, 44143, 44160 .?
*
POSTOPERATIVE DIAGNOSES:
1. Crohn's disease with involvement of the ileocecum and ileosigmoid fistula.
2. Mesenteric abscess.
3. Proximal small bowel mass lesion.
*
PROCEDURE: Exploratory laparotomy with ileocecal resection and primary
anastomosis, proximal small bowel resection and primary anastomosis, sigmoid
colectomy with end colostomy and Hartmann's closure of the rectum.
*
1. Terminal ileum and cecum.
2. Small bowel mesentery.
3. Section of proximal small bowel with mass lesion.
4. Sigmoid colon.
*
COMPLICATIONS: None.
*
OPERATIVE FINDINGS: A large inflammatory phlegmon with intermesenteric abscess
involving the terminal ileum and the cecum, as well as a fistula to the sigmoid
colon. Approximately 300 cm of remaining small bowel after completion of the
case. A mass lesion was found in the proximal small bowel, 15 cm from the ligament of
Treitz, for which a segmental resection was performed; and frozen section
revealed a likely benign neoplasm.
*
INDICATIONS: a long history of poorly
controlled ileocecal Crohn's disease. On recent imaging, he was noted to have a
large inflammatory process involving the terminal ileum and the cecum, as well
as the sigmoid colon with suggestion of a fistula. He has been on anti-TNF
therapy several months, without improvement, and he is now being brought to the
Operating Room for surgical exploration due to progression of symptoms.
*
DESCRIPTION OF PROCEDURE: The patient was identified, brought to the Operating
and placed on the table in a supine position, after obtaining informed consent.
Venous sequential stockings were placed. He was given preoperative intravenous
antibiotics, as well as subcutaneous heparin. After induction of general
endotracheal anesthesia, a Foley catheter was placed. He was repositioned in a
modified lithotomy position, using Yellofin stirrups. Rectal irrigation was
performed, and the abdomen and perineum were prepped and draped in the usual
sterile fashion. A midline incision was made through skin, subcutaneous tissue
and fascia to enter the abdominal cavity. An Alexis wound protector was placed.
Omental adhesions in the pelvis were divided, and the omentum was retracted
cephalad. Immediately, we noted a large inflammatory mass in the lower abdomen
at the base of the mesentery involving the terminal ileum, the cecum and the
sigmoid colon. Using careful dissection, we were able to separate the sigmoid
colon from the inflammatory mass. In the process of doing this, we identified
and divided the fistula between the colon and the phlegmon. We then incised the
lateral attachments of the right colon and mobilized the colon and mesentery
medially off of the retroperitoneum. The hepatic flexure was fully mobilized.
We carefully dissected out adherent loops of small bowel to the mesenteric
phlegmon. We divided the small bowel at the distal most point, where it
appeared to be normal, with a GIA stapler. The junction of the cecum and
ascending colon was divided with a GIA stapler, as well. We then very carefully
mobilized the mesenteric phlegmon away from the retroperitoneum and surrounding
structures. We carefully divided the mesentery supplying this area with Kelly
clamps, securing the proximal pedicles with 0 Vicryl suture ligatures. Once we
had fully divided the mesentery, the mass was passed from the field. There were
some additional enlarged phlegmonous lymph nodes at the base of the mesentery,
with pus emanating from them. We dissected this area free, dividing the
mesentery between Kelly clamps and securing the pedicles with 0 Vicryl suture
Ligatures. Additional mesenteric tissue was sent to pathology.
*
We then ran the small bowel. There was approximately 300 cm of small bowel
remaining. In the proximal small bowel, 15 cm from the ligament of Treitz, was
a mass lesion, which appeared concerning for neoplasm. The small bowel was
divided proximal and distal, giving us 5 cm margins grossly. The mesentery was
divided with LigaSure, removing enlarged lymph nodes in this area as well. This
was sent to Pathology and noted to be what was suspected to be a benign
neoplasm on frozen section.
*
We then turned our attention towards the sigmoid colon. The sigmoid colon was
markedly inflamed and was densely adherent to the retroperitoneum and the
pelvis. Inflammatory adhesions were divided. The white line of Toldt was
incised and the colon and mesentery were mobilized medially off of the
retroperitoneum, identifying and protecting the left ureter. The sigmoid colon
proximal to this area was divided with a GIA stapler. We divided the mesentery
with a LigaSure device, including the inferior mesenteric artery. The mesentery
was divided down to the upper rectum, at which point the mesentery was thinned
out and the upper rectum was stapled with a TA 60 stapler and divided proximal
to the TA staple line. The resected sigmoid colon was passed from the field.
*
At this point, I elected to perform a small bowel anastomosis, as well as an
ileocolic anastomosis, but perform an end colostomy given the amount of
inflammation in the pelvis. The small bowel anastomosis was done first, where
the proximal bowel resection had been performed, using a 75 mm GIA stapler to
approximate the 2 limbs of bowel and a TA 60 stapler to close the common
enterotomy. The TA staple line was imbricated with 3-0 Vicryl seromuscular
sutures and a 3-0 Vicryl seromuscular suture was placed at crotch of the
anastomosis to relieve tension. The mesenteric defect was closed with a running
3-0 Vicryl suture, as well.
*
We then fashioned an ileocolic anastomosis between the neoterminal ileum and the
ascending colon using a 75 mm GIA stapler to approximate the 2 limbs of bowel
and a TA 60 stapler to close the common enterotomy. The TA staple line was
imbricated with 3-0 Vicryl seromuscular sutures and a 3-0 Vicryl seromuscular
suture was placed at the crotch of the anastomosis to relieve tension.
*
We then irrigated the pelvis. Hemostasis was noted to be adequate. We tagged
the end of the rectal staple line with Prolene sutures for it to be identified
at a later date, at the time of colostomy reversal. The abdominal cavity was
copiously irrigated with sterile saline. Hemostasis was noted to be adequate.
Seprafilm was laid in the pelvis before the small bowel was allowed to fall down
into the pelvis. We then created a trephination on the left side of the
abdomen using a muscle splitting technique at a point that had been premarked by
the enterostomal therapist. The end of the colon was able to be exteriorized
through this, keeping proper mesenteric orientation. We then performed a TAP
block using Exparel and 0.25% Marcaine. The wound protector was removed. We
changed gowns and gloves and brought the sterile closing tray into the field.
We placed additional Seprafilm between the omentum and the anterior abdominal
wall. The midline fascia was closed with a running looped #1 PDS suture.
Subcutaneous tissues were irrigated, and the skin was closed with a 4-0 Monocryl
subcuticular closure. Dermabond was placed as a dressing.
*
We then turned our attention towards maturing the colostomy. The distal staple
line was excised with electrocautery, and the ostomy was matured placing 3-0
chromic Brooke sutures circumferentially around the perimeter of the ostomy. An
ostomy appliance was cut to the appropriate size and placed over the colostomy.
*
The patient tolerated the procedure well, with no complications. He was
extubated in the Operating Room and taken to Recovery in satisfactory condition.
All needle, instrument and sponge counts were correct at the end of the case.
I was present throughout the entire procedure.
*
*help , thanks
*
POSTOPERATIVE DIAGNOSES:
1. Crohn's disease with involvement of the ileocecum and ileosigmoid fistula.
2. Mesenteric abscess.
3. Proximal small bowel mass lesion.
*
PROCEDURE: Exploratory laparotomy with ileocecal resection and primary
anastomosis, proximal small bowel resection and primary anastomosis, sigmoid
colectomy with end colostomy and Hartmann's closure of the rectum.
*
1. Terminal ileum and cecum.
2. Small bowel mesentery.
3. Section of proximal small bowel with mass lesion.
4. Sigmoid colon.
*
COMPLICATIONS: None.
*
OPERATIVE FINDINGS: A large inflammatory phlegmon with intermesenteric abscess
involving the terminal ileum and the cecum, as well as a fistula to the sigmoid
colon. Approximately 300 cm of remaining small bowel after completion of the
case. A mass lesion was found in the proximal small bowel, 15 cm from the ligament of
Treitz, for which a segmental resection was performed; and frozen section
revealed a likely benign neoplasm.
*
INDICATIONS: a long history of poorly
controlled ileocecal Crohn's disease. On recent imaging, he was noted to have a
large inflammatory process involving the terminal ileum and the cecum, as well
as the sigmoid colon with suggestion of a fistula. He has been on anti-TNF
therapy several months, without improvement, and he is now being brought to the
Operating Room for surgical exploration due to progression of symptoms.
*
DESCRIPTION OF PROCEDURE: The patient was identified, brought to the Operating
and placed on the table in a supine position, after obtaining informed consent.
Venous sequential stockings were placed. He was given preoperative intravenous
antibiotics, as well as subcutaneous heparin. After induction of general
endotracheal anesthesia, a Foley catheter was placed. He was repositioned in a
modified lithotomy position, using Yellofin stirrups. Rectal irrigation was
performed, and the abdomen and perineum were prepped and draped in the usual
sterile fashion. A midline incision was made through skin, subcutaneous tissue
and fascia to enter the abdominal cavity. An Alexis wound protector was placed.
Omental adhesions in the pelvis were divided, and the omentum was retracted
cephalad. Immediately, we noted a large inflammatory mass in the lower abdomen
at the base of the mesentery involving the terminal ileum, the cecum and the
sigmoid colon. Using careful dissection, we were able to separate the sigmoid
colon from the inflammatory mass. In the process of doing this, we identified
and divided the fistula between the colon and the phlegmon. We then incised the
lateral attachments of the right colon and mobilized the colon and mesentery
medially off of the retroperitoneum. The hepatic flexure was fully mobilized.
We carefully dissected out adherent loops of small bowel to the mesenteric
phlegmon. We divided the small bowel at the distal most point, where it
appeared to be normal, with a GIA stapler. The junction of the cecum and
ascending colon was divided with a GIA stapler, as well. We then very carefully
mobilized the mesenteric phlegmon away from the retroperitoneum and surrounding
structures. We carefully divided the mesentery supplying this area with Kelly
clamps, securing the proximal pedicles with 0 Vicryl suture ligatures. Once we
had fully divided the mesentery, the mass was passed from the field. There were
some additional enlarged phlegmonous lymph nodes at the base of the mesentery,
with pus emanating from them. We dissected this area free, dividing the
mesentery between Kelly clamps and securing the pedicles with 0 Vicryl suture
Ligatures. Additional mesenteric tissue was sent to pathology.
*
We then ran the small bowel. There was approximately 300 cm of small bowel
remaining. In the proximal small bowel, 15 cm from the ligament of Treitz, was
a mass lesion, which appeared concerning for neoplasm. The small bowel was
divided proximal and distal, giving us 5 cm margins grossly. The mesentery was
divided with LigaSure, removing enlarged lymph nodes in this area as well. This
was sent to Pathology and noted to be what was suspected to be a benign
neoplasm on frozen section.
*
We then turned our attention towards the sigmoid colon. The sigmoid colon was
markedly inflamed and was densely adherent to the retroperitoneum and the
pelvis. Inflammatory adhesions were divided. The white line of Toldt was
incised and the colon and mesentery were mobilized medially off of the
retroperitoneum, identifying and protecting the left ureter. The sigmoid colon
proximal to this area was divided with a GIA stapler. We divided the mesentery
with a LigaSure device, including the inferior mesenteric artery. The mesentery
was divided down to the upper rectum, at which point the mesentery was thinned
out and the upper rectum was stapled with a TA 60 stapler and divided proximal
to the TA staple line. The resected sigmoid colon was passed from the field.
*
At this point, I elected to perform a small bowel anastomosis, as well as an
ileocolic anastomosis, but perform an end colostomy given the amount of
inflammation in the pelvis. The small bowel anastomosis was done first, where
the proximal bowel resection had been performed, using a 75 mm GIA stapler to
approximate the 2 limbs of bowel and a TA 60 stapler to close the common
enterotomy. The TA staple line was imbricated with 3-0 Vicryl seromuscular
sutures and a 3-0 Vicryl seromuscular suture was placed at crotch of the
anastomosis to relieve tension. The mesenteric defect was closed with a running
3-0 Vicryl suture, as well.
*
We then fashioned an ileocolic anastomosis between the neoterminal ileum and the
ascending colon using a 75 mm GIA stapler to approximate the 2 limbs of bowel
and a TA 60 stapler to close the common enterotomy. The TA staple line was
imbricated with 3-0 Vicryl seromuscular sutures and a 3-0 Vicryl seromuscular
suture was placed at the crotch of the anastomosis to relieve tension.
*
We then irrigated the pelvis. Hemostasis was noted to be adequate. We tagged
the end of the rectal staple line with Prolene sutures for it to be identified
at a later date, at the time of colostomy reversal. The abdominal cavity was
copiously irrigated with sterile saline. Hemostasis was noted to be adequate.
Seprafilm was laid in the pelvis before the small bowel was allowed to fall down
into the pelvis. We then created a trephination on the left side of the
abdomen using a muscle splitting technique at a point that had been premarked by
the enterostomal therapist. The end of the colon was able to be exteriorized
through this, keeping proper mesenteric orientation. We then performed a TAP
block using Exparel and 0.25% Marcaine. The wound protector was removed. We
changed gowns and gloves and brought the sterile closing tray into the field.
We placed additional Seprafilm between the omentum and the anterior abdominal
wall. The midline fascia was closed with a running looped #1 PDS suture.
Subcutaneous tissues were irrigated, and the skin was closed with a 4-0 Monocryl
subcuticular closure. Dermabond was placed as a dressing.
*
We then turned our attention towards maturing the colostomy. The distal staple
line was excised with electrocautery, and the ostomy was matured placing 3-0
chromic Brooke sutures circumferentially around the perimeter of the ostomy. An
ostomy appliance was cut to the appropriate size and placed over the colostomy.
*
The patient tolerated the procedure well, with no complications. He was
extubated in the Operating Room and taken to Recovery in satisfactory condition.
All needle, instrument and sponge counts were correct at the end of the case.
I was present throughout the entire procedure.
*
*help , thanks